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Alternative Pneumocystis Pneumonia Prophylaxis in Solid Organ Transplants.

Kevin D He1, Linh Nguyen2,3, Maxwell Norris2,3

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Alternative prophylaxis for Pneumocystis pneumonia (PJP) in solid organ transplant (SOT) recipients has risks and barriers. Re-trying trimethoprim-sulfamethoxazole (TMP-SMX) is often feasible after adverse events resolve.

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atovaquonedapsonepneumocystisprophylaxissolid organ transplant

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Area of Science:

  • Transplant medicine
  • Infectious disease prevention
  • Pharmacology

Background:

  • Limited data supports Pneumocystis pneumonia (PJP) prophylaxis with atovaquone or dapsone in solid organ transplant (SOT) recipients.
  • Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent, but alternatives are sometimes used.

Purpose of the Study:

  • To evaluate the safety and efficacy of alternative PJP prophylaxis in SOT recipients.
  • To identify barriers to initiating and continuing PJP prophylaxis.

Main Methods:

  • Retrospective cohort study of adult SOT recipients receiving non-TMP-SMX PJP prophylaxis.
  • Included patients with over one year of follow-up.

Main Results:

  • 34.9% of SOT recipients received alternative PJP prophylaxis, primarily atovaquone.
  • Common reasons for switching from TMP-SMX included hyperkalemia and leukopenia.
  • Breakthrough infections occurred (toxoplasmosis, Nocardia), but no PJP cases were reported. Barriers included cost and prior authorization.

Conclusions:

  • Alternative PJP prophylaxis is associated with risks and initiation barriers.
  • Most patients tolerated TMP-SMX after adverse events resolved, suggesting re-trial is feasible.
  • Re-challenging with TMP-SMX should be considered when clinically appropriate.